Peripheral Arterial Disease: A Guide For GPs

Peripheral Arterial Disease (PAD) is a perilous condition silently affecting millions worldwide. [1] This blog is designed as a short guide for general practitioners and other medical professionals. It contains global and some local statistics of PAD prevalence, presents PAD risk groups, and discusses the compounding effect of smoking and multiple risk factors. It also features basic information on the Ankle-Brachial Index (ABI) as a diagnostic tool, explaining its reference scale and pulse waveform recording, as well as cases when the Toe-Brachial Index is used. You can also download the article as a handy brochure.

What is PAD and how frequent is it?

Peripheral Arterial Disease (PAD) is atherosclerosis (plaque buildup) in the arteries supplying the legs. [1] It is a frequent but underdiagnosed condition, often with severe consequences. They include death, stroke, coronary heart disease, amputations, dementia and cognitive impairment.

Here is some global and local information about its prevalence. PAD affects: 

  • more than 230 million adults worldwide[1] 
  • 6 million (9 %) of the UK population[2]
  • 4.5 million (5.3%) of the population in Germany[3]
  • 4-8 million (6-12%) of the population in France, [4]
  • 3-5 million (5-8%) of the population in Italy[5]
  • in Slovenia, 2000-3000 patients with PAD are discovered on a yearly basis. [6]

Why screen for PAD?

The latest AHA Scientific Statement recommends that PAD screening with ABI is urgently implemented in high-risk populations. TBI should be employed if suspecting medial artery calcification, e.g. in cases of chronic kidney disease (CKD) or diabetes. [1]

Effect of smoking

Smoking is a major risk factor in developing PAD. Smokers are at 2x greater risk of PAD compared to non-smokers. With former smokers, it takes up to 30 years for the PAD risk to reach the non-smoker level. [1]

Effect of combination of risk factors

The duration of hypercholesterolemia and diabetes, the severity of hypertension, and cumulative intensity of smoking show graded relationships with PAD risk. [7]

70% of patients with PAD do not experience symptoms and are thus not diagnosed. The TASC II consensus document recommends Ankle-Brachial Index measurement for all PAD risk groups. [8]

Ankle-Brachial Index. A simple tool in detecting PAD

The Ankle-Brachial Index (ABI) is an effective comparison of blood pressure in the legs and the arms. It is non-invasive and painless. Using MESI mTABLET ABI, the procedure is quick and simple. Therefore, the test can be implemented routinely in both primary and specialised care. The ABI test is extremely important for two reasons: 

  • It is a reliable predictor of PAD. 
  • Due to a high co-occurrence of PAD with other diseases, diagnosed patients have a great chance of early diagnosis of the other diseases such as: 
  • coronary artery disease (CAD) or cerebrovascular disease (CVD): 32% [9]
  1. renal insufficiency (RI): 39.7% [10]
  2. diabetes: 49.7% [11]
  3. metabolic syndrome: 58% [12]/63% (45+) [13]
  4. hypertension: 35–55% [14]
  5. hypercholesterolemia: 60% [15]

ABI pulse waveform recording and ABI reference scale

Let’s take a look at normal and abnormal results of the ABI pulse waveform recording on the MESI mTABLET ABI – a digital, automated ABI-measuring device. 

Normal result

The oscillation graph forms a clear lemon shape. This means that the arteries are elastic and that they responded to being briefly compressed by the cuff. The pulse waveforms have these characteristics (cf. the illustration): 

  1. A rapid rise in the upstroke during systole  
  2. A very sharp peak 
  3. A gradual downstroke 
  4. A presence of dichrotic notch 

Abnormal result

A flattened pulsewave recording or one without the typical lemon shape is an indicator of severe PAD. 

The absence of the pulsations caused by occlusions in the artery makes it impossible to calculate the ankle pressures. Instead of the ABI value, the device will display a “PAD” result. 

The illustration shows a flattened pulsewave recording.

ABI reference scale

ESC Guidelines state the following recommendations in connection with ABI measuring [16]:  

  • Measurement of the ABI is indicated as a first-line non-invasive test for screening and diagnosis of LEAD (Lower-Extremity Artery Disease). 
  • In the case of incompressible ankle arteries or ABI > 1.40, alternative methods such as the Toe-Brachial Index, Doppler waveform analysis or pulse volume recording are indicated. 

Toe-Brachial Index

The Toe-Brachial Index (TBI) is a comparison of blood pressure in the toes and the arms. It is used in diagnosing PAD: 

  • when the ABI measurement cannot be interpreted or is inadequate, 
  • with non-compressible arteries in the legs (diabetes, insufficiency-related calcification), 
  • in patients with excruciating pain in the lower extremities, 
  • in end-stage renal disease, 
  • in patients undergoing dialysis, 
  • in very advanced age, 
  • and/or in patients with lymphedema. 

[1] Criqui MH, Matsushita K, Aboyans V, Hess CN, Hicks CW, Kwan TW, McDermott MM, Misra S, Ujueta F; on behalf of the American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council. Lower extremity peripheral artery disease: contemporary epidemiology, management gaps, and future directions: a scientific statement from the American Heart Association. Circulation. 2021; doi: 10.1161/CIR.0000000000001005

[2] The Vascular Society for Great Britain and Ireland. Peripheral Arterial Disease. Accessed 4 September 2023.

[3] Die Techniker. Periphere arterielle Verschlusskrankheit: Gehtraining mit Fitnessarmband und Telefoncoaching besser als gängige Therapie. [24. May 2023]

[4] HAS. Recommandations pour la pratique clinique: Prise en charge de l’arteriopathie chronique obliterante atherosclereuse des membres inferieurs (indications medicamenteuses, de revascularisation et de reeducation). 2006; Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc Health Risk Manag. 2007;3:229–234.

[5] Oliveri C. 10 April 2017. Arteriopatia periferica (AOP): diagnosi precoce, prevenzione e terapia per ridurre drasticamente le amputazioni. Medici oggi. Springer Healthcare Communications. Accessed 7 August 2023.

[6] Arko J and Sardoč A. 19. 03. 2019. Skrb za žile lahko prepreči kap in infarkt. Primorske novice. Accessed 5 September 2023.

[7] Joosten MM, Pai JK, Bertoia ML et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA. 2012;308(16):1660-1667. doi:10.1001/jama.2012.13415

[8] Norgren L, Hiatt WR, Dormandy JA et al. TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease. Int Angiol. 2007;26(2):81–157

[9] Francisco J, Serrano H et al. Enfermedad arterial periferica: aspectos fisiopatologicos, clinicos y terapeuticos; Rev Esp Cardiol. 2007;60:969–82

[10] Tranche Iparraguirre S et al. Enfermedad arterial periferica e insuficiencia renal: una asociacion frecuente; Nefrologia (Madr.) vol. 32 N.° 3, Madrid 2012

[11] Silbernagel G et al. Prevalence of type 2 diabetes is higher in peripheral artery disease than in coronary artery disease patients; Diabetes & Vascular Disease Research 2015, Vol. 12(2) 146–149

[12] Gorter P et al. Prevalence of the metabolic syndrome in patients with coronary heart disease, cerebrovascular disease, peripheral arterial disease or abdominal aortic aneurysm; Atherosclerosis Journal, April 2004, Volume 173, Issue 2, pp. 361–367

[13] Estirado E et al. Sindrome metabolico en pacientes con enfermedad arterial periferica; Rev Clin Esp.2014;214:437–44

[14] Makin A et al. Peripheral vascular disease and hypertension: a forgotten association?; Journal of Human Hypertension (2001) 15, 447–454

[15] Olin JW et al. Peripheral Artery Disease: Current Insight Into the Disease and Its Diagnosis and Management; Mayo Clinic Proceedings. 2010 Jul; 85(7): pp. 678–692

[16] Aboyans et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS), chapter 10.2 Diagnostic tests.

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